Infections After International Travel

Relevant Diagnoses in Children and Adolescents

Background: Families can acquire infections that are rare or nonexistent in Germany by international travel for business or private reasons and by migration between countries. Children and adolescents have special risk profiles, and their course of illness may be nonspecific and/or severe. A structured travel history is essential so that regionally specific infections will not be overlooked.

Methods: This narrative review is based on publications of the last 25 years that were retrieved by a PubMed search on infections after international travel, with an emphasis on retrospective and prospective studies and on articles with separate data on minors. Further information from books, guidelines, surveillance studies, reports of the Federal Statistical Office of Germany, meta-analyses, reviews, and position statements was considered as well.

Results: Reported case numbers of infectious diseases imported from abroad fell during the COVID-19 pandemic and have since risen again. Among diseases that are usually or exclusively ,acquired abroad, those most commonly affecting children and adolescents were giardiasis, tuberculosis, hepatitis A and malaria, with 695, 372, 344, and 128 cases in 2024. Less common ones included dengue fever (81 cases) and typhoid fever/paratyphoid fever (45 cases).

Conclusion: Regionally specific infections should be considered in the differential diagnosis of fever, gastrointestinal disturbances, and skin conditions in children and adolescents after international travel. It is critical that relevant diseases including malaria and typhoid fever/paratyphoid fever must be promptly diagnosed or ruled out. Because resistance patterns differ across regions of the globe, targeted determination of the pathogenic organism including a resistogram is important. The possibility of chronic infection should be considered in particular after long stays abroad.

Cite this as: Kotsias-Konopelska S, Thielecke M: Infections after international travel: Relevant diagnoses in children and adolescents. Dtsch Arztebl Int 2026; 123: 84–92. DOI: 10.3238/arztebl.m2025.0201

The epidemiology of infectious diseases varies from region to region and is subject to constant change due to factors such as climate change, migration, human-animal interaction, and public health interventions (1, 2).

The World Health Organization (WHO) reported a more than 100-fold increase in weekly chikungunya case numbers in the French overseas département of Réunion (an island in the Indian Ocean) from 30 at the end of 2024 to 4000 in the first quarter of 2025 (3). The incidence of dengue fever is doubling annually worldwide, and autochthonous transmission of both types of arbovirus is occurring in new areas, such as southern France (4, 5, 6). The UK Health Security Agency registered a 64% increase in travel-associated gastrointestinal infections from 2022 to 2024 (n = 2703 in 2024), particularly in children under age 10 (7). Knowledge of local outbreaks is important so that relevant diagnoses will not be overlooked. Travel-related risk exposure increase the probability of regionally specific infectious diseases (e.g., malaria, dengue, schistosomiasis) as well as ubiquitous infections (e.g., influenza or COVID-19) and infections that are preventable with vaccines (e.g., hepatitis A, typhoid fever, influenza). Travel to South America is mainly associated with skin diseases, travel to North Africa and the Middle East with diarrheal diseases, and travel to sub-Saharan Africa and Asia with febrile systemic infections (8, 9, 10, 11, 12, 13).

Adolescents and children, especially younger children, have higher morbidity and mortality from infectious diseases than adults. This is due, among other causes, to immune naivety, poor hygiene and risk awareness, and restrictions on the approval of vaccinations, medications, and barrier measures (2, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19). Adolescents and children are also more likely to suffer from acute diarrhea and cutaneous symptoms. Younger children tend to suffer from gastrointestinal and respiratory infections, older children from systemic febrile infections (11, 13). Persons who travel abroad to visit friends and relatives, so-called VFR travelers, constitute a particular risk group, mainly because many of them are young and because they tend not to implement adequate preventive measures. VFR travelers from Germany are generally persons with a migration background who travel to visit friends or relatives in their country of origin or that of their relatives (13, 16, 17, 18). According to a global GeoSentinel surveillance analysis, 62.1% of travel-associated P. falciparum malaria cases arose in VFR travelers (20).

Travel with a long stay abroad increases the risk of chronic infectious diseases such as tuberculosis, human immunodeficiency virus (HIV) infection, hepatitis B and C, Chagas disease, and helminthiasis. Screening tests for clinically silent infections are important for the prevention of long-term sequelae and vertical transmission (e.g., Chagas disease, HIV, hepatitis B and C) (2, 9, 10, 15, 17, 18, 21).

Learning objectives

This article is intended to enable readers to:

• know the importance of a structured travel history in children and adolescents to enable proper prevention, diagnosis, and treatment;
• be familiar with the differentiated diagnostic approach, including important differential diagnoses for travel-associated diseases;
• and identify common travel-associated infectious diseases from their clinical manifestations.

Methods

This narrative review is based on publications from the past 25 years that were retrieved by a PubMed search on diseases in travelers returning from abroad (search terms, in German and English: “travel-associated diseases,” “children and adolescents,” “pediatric travelers returning from abroad,” and “visiting friends and relatives” in combination with all diseases mentioned in the text). Retrospective and prospective studies as well as publications with separate data on children and adolescents were cited preferentially. Further information was derived from surveillance studies, meta-analyses, responses to queries submitted to the German Federal Statistical Office, books, guidelines, evidence-based reviews, and online statements.

Travel history in children and adolescents: major manifestations and diagnostic evaluation

Fever and gastrointestinal and cutaneous symptoms account for 15–25% of pediatric consultations during or after travel, followed by respiratory and other symptoms (11, 12, 13). For infectious diseases of children and adolescents that are commonly associated with travel abroad, the case numbers in Germany in 2024 were as follows: giardiasis (n = 695), tuberculosis (n = 372), hepatitis A (n = 344) and B (n = 182), shigellosis (n = 283), malaria (n = 128), dengue fever (n = 81), typhoid and paratyphoid fever (n = 5), leptospirosis (n = 30), and amoebiasis (n = 9) (22).

The differential diagnosis can be narrowed down with information from a structured travel history (Table 1) and basic, symptom-oriented diagnostic testing (Table 2). Infants and young children often present with nonspecific symptoms while being at higher risk of severe disease progression. The pathogenic organism should be identified as soon as possible so that targeted treatment can be rapidly initiated when necessary, especially for febrile systemic illnesses (e.g., there should be a low threshold for the drawing of blood cultures to detect typhoid/paratyphoid fever). The identification of the pathogen by culture and resistance profiling is important even for ubiquitous infections like urinary tract infections (9, 10, 11, 12, 13, 16, 23, 24, 25, 26, 27).

Table 1

Exposures and examples of associated infectious diseases

Table 2

Symptom-oriented diagnostic evaluation and selection of indicated (screening) examinations (left column); indication or classification of findings regarding potential differential diagnoses (right column) (9, 10, 16, 23, 24, 26, 27, 32, 33, 38, e5, e23)

eTable 1

Exposures and examples of associated infectious diseases

eTable 2

Symptom-oriented diagnostic evaluation and selection of indicated (screening) examinations (left column); indication or classification of findings regarding potential differential diagnoses (DD), including incubation periods (right column) (9, 10, 16, 23, 24, 26, 27, 32, 33, 38, e5, e25)

For patients either in or outside the hospital who have unexplained fever and need empirical treatment once malaria and dengue have been ruled out, doxycycline or azithromycin are appropriate drugs covering the bacterial pathogens that are most commonly detected in the later course of illness, particularly rickettsiae, leptospires, and salmonella. This conclusion, however, is based on studies in adults and still needs to be confirmed for children and adolescents (1).

Febrile infections

Malaria

Malaria is a life-threatening disease. If fever arises during or after travel to an area where malaria is endemic, diagnostic evaluation must proceed at once and must be repeated if the fever persists. A prolonged incubation period of several years has been observed in rare cases (16, 28).

Over 90% of imported malaria infections originate in Africa (14), but infection is also possible in Asia, Central and South America, and very rarely in Southern Europe. The annually updated malaria maps of the German Society for Tropical Medicine, Travel Medicine, and Global Health (Deutsche Gesellschaft für Tropenmedizin, Reisemedizin und globale Gesundheit, DTG) show the current global distribution of endemic malaria (https://dtg.org/empfehlungen-und-leitlinien/empfehlungen/malaria.html).

Malaria is transmitted by the bite of the Anopheles mosquito, which is active at dusk and at night. Its most common symptoms are fever, headache, aching limbs, and fatigue. Diagnosis is not possible on clinical grounds alone, especially in young children, as nonspecific respiratory or gastrointestinal symptoms are common. Children who grow up in areas where malaria is endemic and have the disease repeatedly acquire semi-immunity, so that subsequent infection may present with mild symptoms such as low-grade fever, headache, and anemia. When such persons move to Germany, their semi-immunity tends to be lost. It is not present in children born in Germany (9, 12, 13, 16, 17, 18).

Fulminant and complicated courses of malaria are particularly common in children up to age 5, mainly in cases of malaria tropica due to Plasmodium (P.) falciparum and (only rarely in tourists) malaria quotidiana due to P. knowlesi. The greater the delay in initiating treatment, the higher the mortality and the risk of serious complications, which, in children, include hypoglycemia, epileptic seizures, lactic acidosis, and severe anemia. Malaria tertiana (P. ovale and P. vivax) and malaria quartana (P. malariae) are usually mild (16, 28).

Microscopy of a thick blood smear is the gold standard for the diagnosis of malaria, yielding information on the Plasmodium species and parasite density that is crucial for therapeutic decision-making. The test result may be falsely negative in the early stages of the disease. Antigen tests provide quick guidance but have significant limitations: for example, low sensitivity at high and low parasite densities and for non-P. falciparum malaria, as well as false positive results due to antigen persistence for up to four weeks after treatment. PCR testing yields additional information about pathogenic species and resistance markers (16).

The choice of treatment depends on the degree of complications and is primarily based on artemisinin-based preparations (Table 3). The first 24 hours after presentation are considered critical even after treatment has been initiated; the guidelines for Germany therefore recommend inpatient treatment for all cases of malaria tropica and quotidiana (16). Data from the Netherlands, however, show that good results can be obtained with outpatient treatment of children, adolescents, and adults with uncomplicated malaria tropica, provided that parasitemia is below 1%, the serum bilirubin is below 1.3 mg/dL, and the fever is of less than 72 hours’ duration. This combination of features was found primarily in persons with suspected semi-immunity (29).

Table 3

Important information about Malaria (9, 10, 16)

P. vivax and P. ovale form persistent liver hypnozoites and require follow-up treatment with primaquine for eradication. A proven glucose-6-phosphate dehydrogenase (G6PDH) deficiency is a contraindication, but does not rule out individually tailored primaquine therapy, depending on the severity of the disease (16, 30). The German AWMF guideline on the diagnosis and treatment of malaria contains details on the management of all subtypes of the disease in adults and children (16).

Dengue and other arboviruses

Viral diseases that are primarily transmitted by mosquitoes and ticks include: early summer meningoencephalitis (ESME), dengue, yellow fever, chikungunya, Zika, Japanese encephalitis (JE), and West Nile fever (10). The currently reported incidence of dengue is particularly high, mainly through importation from Asia (especially Thailand and Indonesia) and South and Central America (especially Brazil and the Caribbean) (2, 14). The incidence in 2024 (737 cases) was 324% higher than in 2023 (31). There are four serotypes of dengue (DENV 1–4), with no cross-immunity. Instead, antibody-dependent enhancement (ADE) occurs, so that persons sustaining a second infection with a different serotype are at higher risk of a severe course. ADE can also affect newborns and infants who are infected for the first time and who still have immunity to other dengue serotypes via maternally derived antibodies (32, 33).

76.5% of all first infections with dengue in children are asymptomatic (34).

Symptomatic dengue infections in children usually present with fever; accompanying symptoms such as severe limb pain or macular rash are less common. The classic course is divided into three phases: the febrile phase (3–7 days), the critical phase around the time of fever resolution, and the convalescent phase.

Warning signs and severe courses—described in ca. 64% of symptomatic infants, 55% of children, and 36% of adults (35)—typically occur during the fever resolution phase. They are accompanied by signs of systemic capillary leakage (particularly common in children) and hemorrhages of varying severity and can progress to dengue shock syndrome (eBox) (32, 33).

eBox

Warning signs and monitoring recommendations for dengue*

eTable 3

Important information about malaria [9, 10, 16]

In the first 5–7 days after symptom onset, the diagnosis can be confirmed with an NS1 antigen rapid test (ideally combined with IgM for higher sensitivity) or a PCR test. No specific treatment is available. Patients with dengue must be monitored at short intervals by clinical evaluation and laboratory testing, daily at first and until recovery. To avoid increasing the hemorrhagic risk, antiplatelet drugs (e.g., ibuprofen) should be avoided (32, 33).

In Germany, the Qdenga vaccine has been approved for persons aged 4 and above. It is recommended by the Standing Committee on Vaccination (Ständige Impfkommission, STIKO) as a travel vaccination for persons with an increased risk of exposure who will be traveling to areas where dengue is endemic and have also had a laboratory-confirmed dengue virus infection in the past (36). Further vaccination recommendations for children traveling to endemic areas exist for the following arboviruses: early summer meningoencephalitis (ESME), Japanese encephalitis (JE), yellow fever, and, since February 2025, chikungunya. Details can be found in the recommendations of the Robert Koch Institute (15, 37).

Rickettsioses

Rickettsioses are caused by intracellular bacteria of various genera and an important differential diagnosis for febrile illnesses during or after travel abroad. Classic types include African tick-borne fever (due to Rickettsia africae, mainly in Sub-Saharan Africa), scrub typhus (due to Orientia tsutsugamushi in the Asian Pacific region), and Rocky Mountain Spotted Fever (RMSF, due to Rickettsia rickettsii, mainly in North and Central America). Contaminated saliva and feces from ticks, lice, mites, and fleas are infectious. The incidence is highest in toddlers and schoolchildren, presumably due to increased vector exposure through outdoor play and closer contact with animals (9, 10, 38, 39).

The symptoms are often nonspecific, especially in children. The presence of one or more eschars (painless, necrotic skin lesions) and/or a maculopapular rash (80% of all children with RMSF, vs. 55% of adults [39]) and thrombocytopenia are characteristic. Depending on the virulence of the pathogen, disease severity can range from mild (e.g., African tick-borne fever) to life-threatening with multi-organ involvement (e.g., scrub typhus and RMSF) (38, 40).

The pathogen can be detected in the acute phase by PCR (sensitivity from blood only 1–27%, from eschar biopsies 18–69%) and after 10–14 days by serology (sensitivity 60–100%, but with high cross-reactivity) (9, 10, 38, e1).

Doxycycline is the antibiotic of choice for RMSF and for severe cases of other rickettsioses, even in children under age 8, because of its efficacy, availability, and favorable side effect profile. In less severe cases, azithromycin is an acceptable alternative (40, e1). The early initiation of targeted treatment on the first suspicion of disease is crucial for a positive outcome in RMSF and scrub typhus, for example (30–70% mortality when treatment is started after more than 5 days’ delay) (38).

Typhoid fever (typhus) and paratyphoid fever

Approximately two-thirds of the 100 to 150 cases of typhoid and paratyphoid fever reported in Germany each year are in persons under age 18, especially older adolescents (22). These infections are now imported mainly from South and Central Asia (especially India and Pakistan), Mexico, and Germany (14) and are mainly transmitted by the ingestion of food that has been contaminated by chronic carriers. Hematogenous spread leads to a systemic illness characterized by fever, severe malaise, myalgia, and gastrointestinal symptoms (at first, mainly abdominal pain and constipation). In the later course of the disease, children under 5 years of age are more likely to develop diarrhea, anemia, hepatitis, and leukocytosis; school-aged children are more likely to develop leukopenia, abdominal pain, central nervous and respiratory symptoms; and adolescents are more likely to develop splenomegaly, thrombocytopenia, and intestinal complications. Roseola, though characteristic, is rare (<20%), and the C-reactive protein (CRP) may be only mildly elevated (9).

Complications usually arise from the third week of illness onward, with leukocytosis as a warning sign: 3% of patients develop intestinal perforation or bleeding, clinically manifest as marked abdominal pain or an acute abdomen. Potential organ complications include myocarditis, encephalopathy, septic arthritis (especially in patients with sickle-cell anemia), meningitis (beware, especially in infants), and osteomyelitis. The mortality of untreated typhoid fever and paratyphoid fever is 12–16%; with treatment, the mortality is less than 1% (9, e2).

Blood cultures (90% detection rate in the first week of illness), stool cultures (sensitive from the second week of illness onward), and PCR tests are mainly used to detect the pathogens Salmonella enterica Serovar typhi and paratyphi (Gram-negative rods). Resistance profiling is essential for the identification of relevant regional resistances, e.g., to amoxicillin, fluoroquinolones, cotrimoxazole (high prevalence in Asia), and cephalosporins (high prevalence in Pakistan and elsewhere) (9, 25).

Empirical treatment can be initiated in mild cases with oral azithromycin (20 mg/kilogram body weight (kgBW) as a single dose for 7 days, maximum 500 mg/day), and in severe cases with intravenous ceftriaxone (75–100 mg/kgBW intravenously as a single dose for 14 days, maximum 2 g/day; potential switch to p.o. during the course of treatment depending on the antibiogram results) (9). 2–5% of infected persons become chronic carriers because the pathogens remain in the gallbladder; children are less likely to become chronic carriers than adults (e3). Chronic carriers should be identified by repeated stool checks starting 24 hours after the end of antibiotic treatment. The existing reporting obligation, hygiene rules, and restrictions on visits to community facilities must be observed. Preventive measures include proper handwashing and food and kitchen hygiene, as well as travel vaccinations, whose efficacy is only approximately 60% (9, e4).

Gastrointestinal infections

In children, unlike in adults, bacterial and nonspecific self-limiting (most likely viral) diarrhea are more common than parasitic diarrhea (13).

Particularly among travelers to Southeast Asia, acute diarrhea with an incubation period of a few days is often due to bacterial infection, e.g., with Campylobacter, Salmonella, enteropathogenic Escherichia-coli strains, or Shigella. The route of transmission is fecal-oral via contaminated food (1, 2, 13). Campylobacter enteritis, followed by salmonellosis (2024: 6914 and 4643 reported cases), are by far the most common reportable bacterial enteritis infections among children and adolescents in Germany (22). Most infections are self-limiting with symptomatic treatment. 1% of all non-typhoid salmonellosis cases take a septic course, especially in infants and immunocompromised persons (e5). Patients with fever, dysentery with bloody diarrhea, or a severe or protracted course can be treated empirically with azithromycin (10 mg/kg once daily for 3 days; maximum 500 mg/day; the pediatric formulation as a suspension has a bitter taste). Because of varying regional resistance patterns, it is important for the pathogen to be identified by stool culture and resistogram from a sample that is taken before antibiotics are administered; in patients with fever, blood cultures should be drawn as well (9, e6, e7).

Protozoan infections such as cryptosporidiosis, giardiasis, and amoebiasis may also be clinically acute (usually with low-grade fever or none, diarrhea, abdominal pain, meteorism, and sometimes weight loss), but they are frequently protracted and oligo- or asymptomatic. Infection is transmitted by the ingestion of infectious cysts in contaminated food and especially water, or else by person-to-person contact (especially in young children). These infections do not cause eosinophilia (9, 10, e8, e9, e10). In 2024, infections with Cryptosporidium (n = 1190) and Giardia duodenalis (n = 695) were the most common entities of this type among children and adolescents in Germany (22). In 2022, 44% of giardiasis cases were acquired abroad, mainly in India, Spain, and Italy (14). In that year, 17.5% of cases across the EU were in the 0–4 age group (e11).

Cryptosporidiosis is normally self-limiting within 1–2 weeks, but immunocompromised persons and infants are at a higher risk of profuse and prolonged diarrhea, marked fluid loss, and electrolyte disturbances (9, 28).

Giardiasis is asymptomatic in 15% of cases (e11). Growth retardation can be a leading sign of chronic infection in children (e10). Oral nitroimidazoles and (off label) albendazole and paromomycin are the main drugs for effective treatment.

Resistance (e.g., to nitroimidazoles, especially in Asia), immune compromise, and immunoglobulin A deficiency can cause treatment failure and recurrence. Chlorine-resistant oocysts (cryptosporidiosis) or cysts (giardiasis) continue to be excreted for weeks after treatment, so swimming pools must not be visited for at least two weeks (9, e8, e11, e12, e13).

Diseases caused by pathogenic amoebae are rare in Germany, with incomplete detection (reporting is mandatory in only three federal states) (22). 10–20% of infections with Entamoeba histolytica are invasive, manifesting as amoebic colitis with watery-mucous or bloody diarrhea or as an amoebic liver abscess with high fever and upper abdominal pain. Newborns and infants are particularly at risk for complications such as necrotizing enterocolitis and toxic megacolon. Metronidazole is effective against invasive infection, followed by paromomycin for purely intraluminal treatment (9). Giardiasis and amoebiasis should be considered in the differential diagnosis of chronic inflammatory bowel disease or malabsorption syndrome (10, e14, e15).

Worm infections (= helminthiasis) can cause a variety of symptoms, mainly gastrointestinal, but can also be asymptomatic or oligosymptomatic. Eosinophilia of uncertain cause should arouse suspicion of helminthiasis; it may be less pronounced in children than in adults (e16) and can also be absent (9). Undiagnosed chronic helminthiasis in childhood can lead to malnutrition and associated physical and neurocognitive developmental delay (e17).

The main routes of transmission are fecal-oral (whipworm, roundworm, dwarf tapeworm), transcutaneous (dwarf threadworm, hookworm, schistosomes), or via insufficiently cooked food (fish tapeworm). Ascaris lumbricoides, Strongyloides stercoralis, and hookworms pass through the lungs as part of their migration cycle and can cause eosinophilic pneumonia (Löffler‘s syndrome). An immune response to schistosome antigens can cause fever, urticaria, and a variety of systemic symptoms (Katayama fever) (9, 10).

The most sensitive method for diagnosing protozoa and worms is (multiplex) PCR from stool samples. Useful stool antigen tests are available, e.g., for Giardia duodenalis and Entamoeba histolytica. The sensitivity of stool microscopy (from three independent stool samples) largely depends on the expertise of the laboratory performing the test but is not limited by the number of pathogens to be diagnosed. Serological testing is important for some helminthic diseases (e.g., schistosomiasis). Helminthic diseases are characterized by a long prepatency period, i.e., an interval of weeks to months from the initial infection to the earliest detectability of the pathogen (9, e10).

Mebendazole, pyrantel embonate, albendazole, ivermectin (off label for children weighing less than 15 kg), and praziquantel are effective drugs; the choice of drug depends on the particular type of helminthic infection (9).

Skin diseases

Symptoms caused by arthropod stings and bites are a common reason for pediatric consultations during and after travel abroad. Climatic changes, physical environmental influences, and an atopic diathesis promote bacterial superinfection. The clinical spectrum includes abscesses, impetigo, pyoderma, and ulcerations (differential diagnosis: cutaneous leishmaniasis, especially in chronic cases) (9, 11, 12, 18). When diagnosing and treating such conditions, the physician should be aware of regional patterns of drug resistance (e.g., methicillin-resistant Staphylococcus aureus [MRSA] in the Americas and Asia) and pathogen virulence (e.g., Panton-Valentine leukocidin [PVL]-producing S. aureus in parts of Africa) (Table 2) (23, 34). PVL-producing S. aureus can cause severe, potentially life-threatening necrotizing pneumonia, fasciitis, and osteomyelitis in addition to skin infections, especially in young, previously healthy children (e18). Aside from bacteria, fungi (e.g. dermatophytes) are another important cause of skin infection (9, 11, 12, 18).

Certain common skin infections can be diagnosed on sight. Larva migrans cutanea (Figure 1a) appears as a migrating, garland-shaped, and very itchy papular efflorescence. It develops when a hookworm larva has entered the subcutaneous tissue after contact with soil that is infested with dog or cat feces (especially on the feet; in children, often also on the hands and buttocks). The infection is self-limiting, but treatment with ivermectin (200 μg/kg as a single dose, repeated after one week if necessary) or topical albendazole has few side effects, is effective, and reduces the risk of bacterial superinfection (9, 13).

Figure

a) cutaneous larva migrans infestation on the foot of a young woman returning from a trip to Costa Rica; b) tungiasis on the little toe of a traveler to Brazil; c) furuncle with central opening in myiasis on the arm of a traveler returning from Brazil.

Ectoparasitic diseases such as tungiasis and myiasis are often imported from Latin America and Africa. Tungiasis is caused by the female sand flea Tunga penetrans traversing the epidermis, usually of the feet, where it then grows to the size of a pea over a few days (Figure 1b). In endemic areas, children are particularly affected. Myiasis is a skin infestation caused by fly maggots (larvae) that hatch from eggs laid by various fly species on human skin or on laundry drying outside, which then penetrate the host tissue (Figure 1c). Both diseases are associated with local pain, itch, and the risk of bacterial superinfection (10, 11, e19). Tungiasis is treated with the topical application of dimeticone preparations (e20, e21). In myiasis, the larvae can be removed by occlusion therapy and extraction or surgical removal. Ivermectin kills the larvae, but they can still trigger an allergic reaction if they remain in the skin (e22).

Conflict of interest statement
SKK is president of the German Society for Tropical Pediatrics and International Child Health (Deutsche Gesellschaft für Tropenpädiatrie und internationale Kindergesundheit, GTP). She has received honoraria from BVKJ, DGPI, and the Bernhard Nocht Institute for lectures on the topic of travel medicine for children and adolescents.

MT states that she has no conflict of interest.

Manuscript submitted on 6 April 2025, revised version accepted on 28 October 2025.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Dr. med. Sarah Kotsias-Konopelska

References

1. Camprubí-Ferrer D, Cobuccio L, Van Den Broucke S, et al.: Causes of fever in returning travelers: A European multicenter prospective cohort study. J Travel Med 2022; 29: taac002

2. Grobusch MP, Weld L, Goorhuis A, Hamer DH, et al.: Travel-related infections presenting in Europe: A 20-year analysis of EuroTravNet surveillance data: Lancet Reg Health Eur 2020; 1: 100001

3. WHO Disease outbreak news. Chikungunya—La Reunion and Mayotte. www.who.int/emergencies/disease-outbreak-news/item/2025-DON567#: ~:text=La%20R%C3%A9union%2C%20France&text=Cumulatively%2C% 20from%20the%20start%20of,been%20reported%20on%20the%20island (last accessed on 13 August 2025).

4. WHO News release: WHO launches global strategic plan to fight rising dengue and other Aedes-borne arboviral diseases. 3.10.2024. www.who.int/news/item/03-10-2024-who-launches-global-strategic-plan-to-fight-rising-dengue-and-other-aedes-borne-arboviral-diseases (last accessed on 01 August 2025).

5. ECDC. Communicable disease threats reports. Weekly bulletin. Week 30, 19–25 July 2025. www.ecdc.europa.eu/sites/default/files/documents/communicable-disease-threats-report-week-30_0.pdf (last accessed on 13 August 2025).

6. Santé publique France/Surveillance sanitaire /Bulletin hebdomadaire/Semaine 30–2025. Edition Nationale/Publication : 23 juillet 2025. www.santepubliquefrance.fr/content/download/732324/4711906?version=1 (last accessed on 13 August 2025).

7. Food Safety News. 24. July 2025. www.foodsafetynews.com/2025/07/ukhsa-reports-increase-in-travel-related-foodborne-illness/ (last accessed on 30 July 2025).

8. Lovey T, Hasler R, Gautret P, Schlagenhauf P: Travel-related respiratory symptoms and infections in travellers (2000–22): A systematic review and surve-analysis. J Travel Med 2023; 30: taad081

9. Deutsche Gesellschaft für Pädiatrische Infektiologie: DGPI Handbuch. Infektionen bei Kindern und Jugendlichen. 8th edition. Stuttgart: Thieme Verlag 2025.

10. Meyer C: Tropenmedizin. ecomed MEDIZIN 2019.

11. Herbinger KH, Drerup L, Alberer M, Nothdurft HD, Sonnenburg Fv, Löscher T: Spectrum of imported infectious diseases among children and adolescents returning from the tropics and subtropics. J Travel Med 2012; 19: 150–157

12. West NS, Riordan FA: Fever in returned travellers: A prospective review of hospital admissions for a 2 1/2 year period: Arch Dis Child 2003; 88: 432–4

13. Hagman S, Neugebauer R, Schwartz E: Illness in children after international travel: Analysis from the GeoSentinel Surveillance Network. Pediatrics 2010; 125: e1072–e80

14. Abu Sin M: Infektionsepidemiologisches Jahrbuch des Robert Koch-Instituts: Robert Koch-Institut 2022.

15. Robert Koch Institut: Empfehlungen der Ständigen Impfkommission (STIKO) und der Deutschen Gesellschaft für Tropenmedizin, Reisemedizin und Globale Gesundheit e. V. (DTG) zu Reiseimpfungen. Epidemiologisches Bulletin 14/2025. https://edoc.rki.de/handle/176904/12569.2 (last accessed on 3 April 2025).

16. DGI e.V., DTG e.V., GTP e.V.: AWMF Leitlinie „Diagnostik und Therapie der Malaria“. AWMF Leitlinienregister 2025. https://register.awmf.org/assets/guidelines/042-001l_S1_Diagnostik-Therapie-Malaria_2025-09.pdf (last accessed on 9 December 2025).

17. Angell S, Behrens RH: Risk assessment and disease prevention in travelers visiting friends and relatives. Infect Dis Clin N Am 2005; 19: 49–65

18. Flores S, Hickey PW, Fields JH, Ottolini MG: A „syndromic“ approach for diagnosing and managing travel-related infectious diseases in children. Cur Probl Pediatr Adolesc Health Care 2015; 45: 231–43

19. Piché-Raynaud PP, Hoang Nguyen J, Pell LG: Underestimation of travel-associated risks by adult and paediatric travellers compared to expert assessment: A cross-sectional study at a hospital-based family pre-travel clinic. Travel Med Infect Dis 2022; 47: 102315

20. Leder, Karin, Torresi J, Libman MD, et al.: GeoSentinel surveillance of illness in returned travelers, 2007–2011. Ann Intern Med 2013; 158: 456–68

21. Greenaway C, Castelli F: Infectious diseases at different stages of migration: An expert review. J Travel Med 2019; 26: taz007

22. Robert Koch-Institut: SurvStat@RKI 2.0, https://survstat.rki.de (last accessed on 17 October 2025).

23. Darboe S, Dobreniecki S, Jarju S, et al.: Prevalence of panton-valentine leukocidin (PVL) and antimicrobial resistance in community-acquired clinical staphylococcus aureus in an urban gambian hospital: A 11-year period retrospective pilot study. Front Cell Infect Microbiol 2019; 9: 170

24. Jaradat ZW, Khwaileh M, Al Mousa W, Ababneh QO, Al Nabulsi A: Occurrence, distribution and pattern analysis of methicillin resistant (MRSA) and methicillin sensitive (MSSA) staphylococcus aureus on fomites in public facilities. Pathog Glob Health 2021, 115: 377–91

25. Hancuh M, Walldorf J, Minta AA, et al.: Typhoid fever surveillance, incidence estimates, and progress toward typhoid conjugate vaccine introduction—worldwide, 2018–2022. Morb Mortal Wkly Rep 2023; 72: 171–6

26. Thielecke M, et al.: Krank angekommen aus tropischen Ländern Malaria, Typhus und Differenzialdiagnosen. Pädiatrie 6/2023; 27–35

27. Kotsias-Konopelska S, Thielecke M, Vanegas-Ramirez A: Kinder auf Reisen—häufige und wichtige reiseassoziierte Infektionen. Monatsschrift Kinderheilkunde 7/2025; 544–51

28. Choutos D, Poulaki A, Piperaki ET: Malaria in children: Updates on management and prevention. Pediatr Infect Dis J 2023; 42: e116–e8

29. Bottieau E, Clerinx J, Colebunders R, etal.:. Selective ambulatory management of imported falciparum malaria: a 5-year prospective study. Eur J Clin Microbiol Infect Dis 2007; 26:181–8

30. Chen I et al.: Safety of single-dose Primaquine in G6PD-deficient and G6PD-normal males in Mali without Malaria: An open-label, phase 1, dose-adjustment trial. J Infect Dis. 2018; 217: 1298–308

31. Lachmann R, Frank C: Starker Anstieg der Denguefieber-Meldefallzahlen in den ersten Monaten 2024. Epid Bull 2024; 20/21: 3–8.

32. Paz-Bailey G , Adams LE, Deen J, Anderson KB, Katzelnick LC: Dengue. Lancet 2024; 403: 667–82

33. Verhagen L, de Groot R: Dengue in children. J Infect 2014; 69: S77–S86

34. Bos S, Zambrana JV, Duarte E, et al.: Serotype-specific epidemiological patterns of inapparent versus symptomatic primary dengue virus infections: A 17-year cohort study in Nicaragua. Lancet Infect Dis 2025; 25: 346–56

35. Hammond SN, Balmaseda A, Pérez L, et al.: Differences in dengue severity in infants, children, and adults in a 3-year hospital-based study in Nicaragua. Am J Trop Med Hyg 2005; 73: 1063–70

36. Robert Koch-Institut: Pressemitteilung der Ständigen Impfkommission (STIKO) und der Deutschen Gesellschaft für Tropenmedizin, Reisemedizin und Globale Gesundheit e.V. (DTG) zur Empfehlung des Dengue-Impfstoffes Qdenga. 30.11.24. www.rki.de/DE/Themen/Infektionskrankheiten/Impfen/Staendige-Impfkommission/Empfehlungen-der-STIKO/PM/PM_2023-30-11.html (last accessed on 6 August 2024).

37. Robert Koch-Institut. Impfempfehlung, Stand 10.07.2025. www.rki.de/SharedDocs/FAQs/DE/Impfen/Chikungunya/FAQ-Liste_Impfempfehlung.html#entry_16946300] (last accessed on 10 August 2025).

38. Sood A, Sachdeva A: Rickettsioses in children—a review. Indian J Pediatr 2020; 87: 930–6

39. Álvarez-López DI, Ochoa-Mora E, Nichols Heitman K, et al.: Epidemiology and clinical features of rocky mountain spotted fever from enhanced surveillance, Sonora, Mexico: 2015–2018. Am J Trop Med Hyg 2021: 104; 190–7

40. McClain MT, Sexton DJ, Hall KK: Scrub Typhus. UpToDate.com (last accessed on 10 August 2025).

e1. Paris DH, Dumler JS: State of the art of diagnosis of rickettsial diseases: The use of blood specimens for diagnosis of scrub typhus, spotted fever group rickettsiosis, and murine typhus. Curr Opin Infect Dis 2016; 29: 433–9

e2. Parry C, Tinh Hien T, Dougan G, White NJ, Farraret JJ: Typhoid fever. N Engl J Med 2002; 347: 1770–82

e3. Bhutta, Zulfiqar A: MB, BS, FRCP, FRCPCH, PhD. Typhoid fever: Current concepts. Infect Dis Clin Pract 2006; 14: 266–72

e4. RKI Ratgeber: Typhus abdominalis, Paratyphus. www.rki.de/DE/Aktuelles/Publikationen/RKI-Ratgeber/Ratgeber/Ratgeber_Typhus_Paratyphus.html?nn=16904322#doc16804168bodyText15 (last accessed on 28 March 2025).

e5. Levy J: Diagnostic approach to diarrhea in children in resource-abundant settings. In Teach SJ, Duryea T, Wiley J Editors. www.uptodate.com. (last accessed on 17 July 2025).

e6. Zwiauer K: Reisediarrhö. Monatsschr Kinderheilkd 2018; 166: 297–304

e7. Fachinformation Azithromycin 1A Pharma 200mg/5ml Suspension. Stand September 2025.

e8. RKI Ratgeber: Kryptosporidiose. www.rki.de/DE/Aktuelles/Publikationen/RKI-Ratgeber/Ratgeber/Ratgeber_Kryptosporidiose.html?nn=16906568#doc16792542bodyText10 (last accessed on 9 December 2025).

e9. Hommes F, Dörre A, Behnke SC, Stark K, Faber M: Autochthonous and imported giardiasis cases: An analysis of two decades of national surveillance data, Germany, 2002 to 2021. Euro Surveill 2024; 29: 2300509

e10. Leder K, Ryan E, Bogorodskaya M: Giardiasis: Epidemiology, clinical manifestations and diagnoses. UpToDate.com. Last update (last accessed on 17 July 2025).

e11. European Centre for Disease Prevention and Control. Giardiasis. In: ECDC. Annual epidemiological report for 2022. Stockholm: ECDC; 2024.

e12. Carter ER, Nabarro LE, Hedley L, Chiodini PL: Nitroimidazole-refractory giardiasis: A growing problem requiring rational solutions. Clin Microbiol Infect 2018; 24: 37–42

e13. Gesellschaft für Pädiatrische Gastroenterologie und Ernährung (GPGE) et al.: AWMF S2K Leitlinie „ Akute infektiöse Gastroenteritis im Säuglings-, Kindes- und Jugendalter—Update 2024“. https://register.awmf.org/assets/guidelines/068-003l_S2k_AGE-Akute-infektioese-Gastroenteritis-Saeuglinge-Kinder-Jugendliche-2024-07.pdf (last accessed on 10 August 2025).

e14. Manthey C, Epple HJ, Keller KM, et al.: S2k-Leitlinie Gastrointestinale Infektionen der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). https://register.awmf.org/assets/guidelines/021–024l_S2k_Gastrointestinale_Infektionen_2023–11_1.pdf (last accessed on 10 March 2025).

e15. Richter J, Heintges T, Thomassen D, Tannich E, Häussinger D: An unsuspected cause of chronic colitis. Gut 2006; 55: 832

e16. Rabinowicz S, Leshem E, Schwartz E: Acute schistosomiasis in paediatric travellers and comparison with their companion adults. J Travel Med 2021; 28: taaa238

e17. Taylor-Robinson DC, Maayan N, Soares-Weiser K, Donegan S, Garner P: Deworming drugs for soil-transmitted intestinal worms in children: Effects on nutritional indicators, haemoglobin, and school performance. Cochrane Database Syst Rev 2019; 9: CD000371.

e18. Hoppe PA, Holzhauer S, Lala B, et al: Severe infections of Panton-Valentine leukocidin positive Staphylococcus aureus in children. Medicine 2019; 98: e17185

e19. Freedman DO, Weld LH, Kozarsky PE, et al.: Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006; 354:119–30

e20. Thielecke M, Nordin P, Ngomi N, Feldmeier H: Treatment of tungiasis with dimeticone: A proof-of-principle study in rural Kenya. PLoS Negl Trop Dis 2014; 8: e3058

e21. Miller H, Trujillo-Trujillo J, Mutebi F, Feldmeier H: Efficacy and safety of dimeticones in the treatment of epidermal parasitic skin diseases with special emphasis on tungiasis: An evidence-based critical review. Braz J Infect Dis 2020; 24: 170–7

e22. Solomon M, Lachish T, Schwartz E: Cutaneous myiasis. Curr Infect Dis Rep 2016; 18: 28

e23. Rothe C, Veit O, Rosenbusch D, et al.: Empfehlungen zur Malariaprophylaxe. Flugmedizin, Tropenmedizin, Reisemedizin 2024; 31: 165–206

e24. Remé T, Jentsch KD, Steinmann J: Recommendation for post-exposure prophylaxis after potential exposure to herpes b virus in Germany. J Occup Med Toxicol 2009, 4: 29

e25. Erhardt S, Burchard G: Eosinophilia in returning travelers and migrants. Dtsch Arztebl Int 2008; 105: 801–7